Refeeding syndrome in at-risk hospitalized children: A descriptive study

Refeeding syndrome is a metabolic condition characterized by severe electrolyte disturbances following nutritional rehabilitation in malnourished patients, with limited pediatric evidence. This study evaluated the implementation of locally adapted international guidelines in a Middle Eastern tertiary care setting.

We performed a descriptive cohort study of 133 children (28 days to 14 years) at the Children's Specialized Hospital, King Fahad Medical City (June 2024 to May 2025), stratified by refeeding syndrome risk. Our primary outcome was refeeding syndrome, defined as hypophosphatemia, hypokalemia, and/or hypomagnesemia 10% or more below normal limits within 5 days of nutritional support initiation. Secondary outcomes were length of stay, intensive care unit admission, hospital mortality, and weight change at 6 months.

Of 1,117 admissions, 133 patients were enrolled (median age 24 months; 44.4% male; 61.7% severe risk). Underlying conditions included failure to thrive (21.1%), syndromic conditions (15.0%), and neurological impairments (12.8%). Refeeding syndrome developed in 13 patients (9.8%; 95% CI: 5.6 to 16.1%). A nonsignificant increase was observed across risk categories (p = 0.43). Lower body mass index z-scores correlated with refeeding syndrome (tau b = 0.163, p = 0.02). All 13 patients required electrolyte correction. Thiamine prophylaxis reached only 9 of 82 severe-risk patients (11.0%) despite 97.7% risk identification, revealing a critical implementation gap. Weight recovery was significant at 6 months.

Refeeding syndrome affects 1 in 10 pediatric patients. Risk stratification was associated with the absence of severe complications despite imperfect implementation. A critical gap in thiamine adherence (11.0%) demonstrates that guideline adaptation requires systematic implementation strategies beyond protocol development.

This descriptive cohort study establishes that refeeding syndrome affects 9.8% (95% confidence interval: 5.6%-16.1%) of at-risk pediatric patients following the implementation of adapted American Society for Parenteral and Enteral Nutrition (ASPEN)/National Institute for Health and Care Excellence (NICE) guidelines in a tertiary care setting. Systematic risk stratification successfully prevented severe complications, with zero pediatric intensive care unit admissions and zero mortality attributable to refeeding syndrome. However, thiamine prophylaxis was received by only 9 of 82 severe-risk patients (11.0%) for whom it was indicated per protocol, despite 97.7% risk identification, revealing a critical implementation gap. These results provide evidence-based refeeding syndrome incidence benchmarks for similar pediatric populations and underscore that effective nutrition support requires comprehensive quality improvement strategies addressing system-level barriers to protocol adherence.